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DEVELOPMENT OF A THERAPEUTIC COMMUNITY
Problems Encountered in Daily Community Meetings

FRANK L. RUNDLE, Lieutenant, MC, USNR
DENNIE L. BRIGGS, Lieutenant, MSC, USN

Text and Permissions: Dennie Briggs
html: Craig Fees


U. S. ARMED FORCES MEDICAL JOURNAL   (Vol. VIII, No. 9  September 1957) 1339-1349

From U. S. Naval Hospital, Yokosuka, Japan.
Dr. Rundle is now at the Payne Whitney Clinic,
New York Hospital, 525 E. 68th St., New York, N. Y.

 

DEVELOPMENT OF A THERAPEUTIC COMMUNITY
Problems Encountered in Daily Community Meetings

FRANK L. RUNDLE, Lieutenant, MC, USNR
DENNIE L. BRIGGS, Lieutenant, MSC, USN

 

IN A previous article,1 we dealt with the initial problems encountered in the operational transition of a closed psychiatric ward in an overseas naval hospital from traditional management methods to those embodied in the concept of the therapeutic community as developed by Jones2 and Wilmer.3,4 About 6 weeks after the program was initiated, the previously described daily group discussions on the closed ward were extended to include the entire service. The size of the group meetings after the open ward was added reached a maximum of 120 patients and staff.

For several weeks, developments were satisfactory and encouraging, and then a series of incidents occurred that necessitated dividing the community into two separate parts, the closed and open wards. The most important factors involved in this disorganization were the marked heterogeneity of the patient population, premature relaxation of some of the former closed ward restrictions, and a lack of adequate communication between members of the staff and between staff and patients. After about three months it was again possible to establish the service as a total community, and it has been operating as such since that time.

One of the most important results of the adoption of the community method has been the elimination on the closed ward of all forms of mechanical restraint, including seclusion rooms. These have been used during the past five months only for segregation of disturbed drunk patients. The use of sedation on both wards is now rarely necessary, and the ataractic drugs are used only occasionally to control severely anxious and disturbed individuals.

Currently all patients and staff meet for 45 minutes six mornings weekly for the community group meeting. Following each meeting, the staff meets to bring together all information available about patients and to discuss the meeting just held. Subsequent to that, the closed-ward patients meet with the ward corpsmen for a second group discussion. In addition, many open ward patients are assigned to small therapy groups, these being led by the nurse and senior corpsman, under supervision of the medical officers. A few patients are given individual psychotherapy, but the treatment for most is almost entirely within the community setting. In addition to the meetings described, the closed-ward staff meets early each morning to exchange information and observations; and one afternoon weekly the entire staff meets in a group designed primarily for working out staff interpersonal difficulties.

During the period covered by this article, a number of problems arose repeatedly. They will be presented here, together with some of the methods developed to deal with them.

PROBLEMS OFTEN ENCOUNTERED IN COMMUNITY MEETINGS

Here and Now Problems. Jones2 and Wilmer3 have pointed out that often the most important material for treatment is contained in day-by-day behavior and the feelings involved in interpersonal relationships. Initially, the importance of dealing with these obvious factors was overlooked; instead, patients were encouraged to reveal and discuss deep inner feelings and ideas. As a result, many opportunities that arose in the frequent interpersonal difficulties were lost. When it became clear that this was the case, the emphasis was shifted and all members of the community were encouraged to bring up the small aggravations, annoyances, tensions, and resentments that arose within the community. In many cases this led to discussion and working through of underlying personal problems, even though they were not primarily emphasized.

Naming Names. In this community there has been extreme reluctance to reveal names of persons discussed, when the behavior involved was in any way antisocial, unacceptable, or could be considered an offense under military law. For instance, a patient may bring up in the group meeting, “There’s a patient drinking on the ward, I’m not saying who it is but . . ” In such a case, he would be interrupted and asked to name the person about whom he was talking. If he refused, he would be discouraged from continuing unless the person involved should speak up. If the person did not speak up, the group would be asked whether anyone could assist in determining who was being discussed. If this failed, the matter would be allowed to drop even though it would seem important that the issue be settled. The exposure of antisocial behavior before the group usually causes embarrassment and discomfort in the individual concerned and resentment toward him by his peers. These factors constitute social pressure, which if handled property may be used effectively to bring about alterations in behavior patterns. If names are not revealed, this pressure cannot he usefully employed. The staff is also required to identify persons discussed, and many times the patients will call their attention to the need to do so.

Another reason it is believed necessary to name names is to prevent introduction to the group of factually inaccurate information. On one occasion, a 17-year-old youth with a basically schizophrenic make-up, whose constant acting out was provocative and designed to arouse hostilities between patients and Staff, asked what would be done if it were learned that narcotics were being brought on the ward. At that time it was not insisted that he make clear what he meant and name those involved; the discussion continued on a hypothetical level, and three patients who were under investigation for narcotics use became extremely angry and disturbed as they believed that suspicion was being cast upon them. Other patients seemed to become angry and anxious about the situation, and it was only after several meetings that all the feelings and tensions had been worked through and the facts of the matter established. Most of the difficulty could have been avoided had the person who introduced the subject been forced to name names or admit that he had no reason to think that narcotics had actually been brought on the ward.

Patients often took the attitude that informing on persons involved in illegal activities would be “squealing” or “ratting’ and that this would disrupt friendships and social standing on the ward. Sometimes patients openly interfered with the efforts of the staff to encourage the revealing of such information. In such instances, the staff pointed out that withholding information which aided another to escape detection of antisocial behavior was not helping him in terms of real treatment, which was the object of his hospitalization. Occasionally the example was cited by staff or patients of a patient who a few months before went AWOL and later was found dead of an overdose of heroin. Many patients on the ward knew that he was going AWOL and, in fact, some co-operated with him, but none had alerted the staff. In this instance it was clear that had someone “squealed” it would have been a worthy and constructive action.

When the person named in cases involving socially unacceptable behavior is a member of the hospital staff, it is important to have that person present even though he is not a member of the psychiatric staff. In some instances, staff personnel from other departments, such as the master-at-arms staff, who were named by patients as having been involved, were invited to attend the group meeting, with beneficial results for the community and for themselves. In some cases the person named was in such a position that it was impossible to obtain his presence at the discussion; this was one of the disadvantages that was inherent and unalterable and hence had to be accepted.

Confessions. It was found that it often was unwise to allow patients to be “pressured” by the group into discussing a matter of deep personal concern that would be in the nature of a confession, because it would make the person liable to legal proceedings. This problem arose chiefly in connection with sexual matters that under the Uniform Code of Military Justice are illegal, particularly homosexuality and other “perversions.” In this military setting it was found that it was impossible to deal with such matters therapeutically, because of legal and administrative attitudes, as well as the secondary attitudes that arose from them. In a few instances in which group pressure resulted in confession of material that could not be adequately worked out, the effect on the person involved and the group as a whole was considered to be detrimental. If a staff member realized that, a patient was being pushed toward revelation of such personal, highly charged emotional material, the process was interrupted directly.

Legal Entanglements. Related to the problem of naming names and handling confessions was that of what action to take when cases of infraction or violation of laws or regulations arose in the group meetings. The social pressures operative within the therapeutic community were such as sometimes to cause information to be revealed that could lead to legal action and punishment. This arose most frequently in instances of drinking or gambling in the hospital, going AWOL, and financial indebtedness to other patients. In such cases the decision was made individually as to whether taking legal action would be beneficial in terms of conscience development or relief of guilt.

Sometimes the decision as to whether legal action should be taken was influenced by the manner in which the community responded to the situation. It was interesting to see how emphasis on honesty and truthfulness and conformity to social rules and customs sometimes promoted the acceptance of such qualities by patients. Often patients would seek private interviews to reveal their own infractions of rules, knowing full well that to do so was to invite legal action. In the community, it was emphasized that members must face their social responsibilities to the group, and that they should not seek to escape punishment by private revelation of guilt. Sometimes patients on the eve of their departure from the hospital would confess to having committed some illegal act, stating that they just could not leave without “getting it off their chest.” On occasion they offered concrete suggestions as to how we could help other patients who engaged in such behavior, usually indicating that they believed the staff’s attitudes to be too lenient.

Antisocial Behavior. Situations which were indications for legal action have been discussed, but in the therapeutic community problems constantly arose that involved antisocial behavior of a nature which would not justify formal legal action. Examples of such behavior were failing to observe reveille, refusal to perform work details, making noise after taps, and using the property of others without permission. Such matters, although they seem minor, often led to intense friction and hence were the subject of discussion in the large group meetings.

When such behavior was discussed, the offender was first asked if he could explain his actions to the group; then the group was asked to express opinions and feelings. Patients and staff have indicated many times that on occasion they had conformed to rules and social expectations because they dreaded having their actions examined and discussed by the group.

There were certain situations involving antisocial behavior that consistently caused considerable tension and tended to disrupt the community; hence the rules and social requirements were strictly enforced. Examples of such situations were non-attendance at group meetings, gambling, consumption of alcohol within the hospital, and borrowing money. When possible these matters were dealt with within the community, but in some cases legal action was taken. On one occasion a patient was placed on report for deliberately evading attendance of group meetings despite repeated warnings; for this, and the fact that he lied when he appeared at Captain’s Mast, he was awarded a court-martial. At that time this action seemed drastic, but in the long run the effect was beneficial to the community and to the patient.

Occasionally antisocial behavior of a staff member on or off the psychiatric service was discussed in the group meetings. In such cases the situation was handled no differently than if it were a patient who was involved, so as to make it clear to staff and patients that the staff as well as the patients were expected to observe community rules and customs. Once a staff corpsman from another hospital department aided a psychiatric patient in going AWOL and also borrowed money from him. This staff personnel was invited to attend the group meeting and was asked for an explanation. The patients in general tended to excuse and defend him, but the outcome was that he was placed on report and legal action was initiated.

One of the greatest difficulties in regard to the problem of minor acting-out by patients was a lack of consistency among the staff corpsmen in enforcing rules. For the most part this has been overcome by an active teaching program and frequent staff meetings, wherein efforts are constantly made to maintain open communication among the staff. Another problem was that the staff corpsmen were reluctant to introduce to the group, information concerning relatively minor antisocial behavior by patients or staff. They seemed to feel that such things were not important enough to warrant the group’s consideration. Also, at first, there seemed to be an attitude that this would be “squealing.” This problem was gradually overcome as the staff became educated and experienced and felt secure in their position in the community.

Recently it seemed that in the group discussions too much emphasis was being placed on the misbehavior of patients, which led to the attitude among many of the patients that they were being “placed on trial.” In retrospect, it appeared that the approach was too moralistic, without sufficient effort to understand why such behavior occurred. When this was realized, a deliberate attempt was made to shift the emphasis. At present it cannot be said which approach was the more useful in the operation of this particular therapeutic community.

The Indefinite Answer. Sometimes patients indicated in the group meetings that they were angry with or disappointed in the staff because questions or issues were not squarely met and answered or settled. In general, questions directed to the staff were reflected back to the person asking them, or were passed on to the group, as often a question was asked primarily as an opening for discussion rather than to obtain a direct answer. Sometimes it was necessary to answer a question directly and concretely. This was so especially with questions concerning psychiatric illnesses, diagnoses, theories, and treatment. In such cases a simple, honest, direct answer was useful in educating patients, in clarifying misconceptions, in allaying anxiety, and in removing the shroud of mystery that so often surrounds such matters.

When a question discussed in a meeting appeared not to have been adequately answered, a staff member would state the issue, summarize the discussion, and give an explanation or answer if possible; if none was possible, he would say so plainly. Often patients remarked, “Why not just say there is no answer, rather than beat around the bush?”

Only the Doctor Can Help Me. An opinion frequently expressed in the discussions was that because most of the group were patients and had problems of their own, it would be futile to introduce personal problems to the group for their consideration and assistance. Another phase of that attitude was the belief, held by most patients when they came to the hospital, that any help must come from the doctor himself. To many, being a patient involved passively co-operating with the doctor’s orders in the hope that relief from distressing symptoms would ensue. Perhaps this procedure would work in some aspects of medical or surgical treatment, but in psychiatry it would be inimical to the treatment process.

When a patient in the meeting brought up his feeling that only the doctor could help him, several approaches were utilized. Obviously there were occasions when the reality situation was such that only individual psychotherapeutic treatment could be expected to give relief, and this was arranged for when possible. In other cases, in which it was believed that the therapeutic community effect would be beneficial, the approach was designed to aid the person in understanding how the community operated and what could be expected if he entered into it. One way of dealing with the problem was for one of the doctors present to call attention to his presence and that of other doctors, and to point out that they were there to help in any way they could. Another approach was to make a simple statement that in the past it had been found that patients could be of great help to other patients, Sometimes it was pointed out that in cases involving difficulties in getting along with people, working them out with the doctor alone would not necessarily ensure that the solutions could be applied outside the individual therapeutic setting. It was pointed out that in some cases the working through of such difficulties in a large group would be more beneficial. Often, patients who had been in the hospital for some time gave “testimonials” that they actually did receive benefit and assistance from other patient members of the group.

From the beginning a deliberate attempt has been made to foster the attitude that patients, as members of the community, have responsibilities in the treatment of other patients. This attitude was developed and perpetuated only by constant and persistent efforts by the staff. An example of a way in which patients shared with the staff in the treatment of a patient was that of a career sailor who had made a nearly successful suicidal attempt. On the closed ward, under the unobtrusive supervision of the staff, the patients stood “special watches’ over him and aided in his nursing care. Later, when this patient was ready for transfer to the open ward, he requested that he be allowed to remain on the closed ward in order that he might share in the treatment of more seriously ill patients and thus discharge his “debt” to the community and show his gratitude to the group, Following extensive surgical repairs and physical therapy, this patient was restored to full duty.

An important part of functioning of the therapeutic community as developed here was that the patients shared directly with the staff the responsibility for care of psychotic patients, especially those who were seriously disorganized. Several patients who were confused, disoriented, agitated, hallucinating, and delusional were cared for by patients in co-operation with the staff in such a manner that these patients were never left alone except when they slept. In some cases, catatonic patients were “forced” to leave their beds, play games, eat meals, take showers, and shave, through the efforts of the group. They were never abandoned to their private, autistic worlds of fantasy, hallucinations, or delusion. They were faced with reality nearly 24 hours daily, which included their being drawn into social relationships, both individual and group. Sometimes disorganized patients during lucid intervals would adopt this helpful attitude toward others who at the moment were less well than they. In several instances, acutely schizophrenic patients showed dramatic improvement after 2 or 3 days of such treatment, such improvement not having been observed prior to institution of therapeutic community methods. Of course, there were other schizophrenic patients who did not improve. Because of the short time period involved and the lack of follow-up information on these patients, it is impossible to draw any conclusions as to the efficacy of this treatment in terms of the over-all disease process. It is believed, however, that because this treatment was begun within hours or days of an acute psychotic disorganization, with at least interruption of the disease process, the likelihood of its having permanent beneficial effect would be great.

The limitations of community means of treatment are realized, in that emphasis is on social recovery rather than on personality reorganization; however, if the means to do individual interpretive psychotherapy are not available, social recovery is an important achievement and may have equally ambitious goals.

There’s Nothing Wrong With Me. Inasmuch as the majority of patients with whom this article deals were admitted to the hospital not because of their own request for aid but because of various external circumstances, there were many who maintained the attitude that there was nothing wrong with them and that they should not be in the hospital. This was in fact true of some patients, and they were returned to duty as soon as possible. Those who were retained despite their belief that it was unnecessary were particularly resistant to acculturation into the therapeutic community, and often attempted to disrupt the group discussions with their insistence that they were perfectly well and should not be in the hospital. This situation was usually recognized by other patients who had been in the community for some time and were quite skilled at uncovering and pointing out denials, inconsistencies, and rationalizations. When the group did not do this spontaneously, a staff member posed the question, “Does anyone see any reason why this man should be in the hospital?” This usually was sufficient to start the process of dealing with the man’s resistances. One of the most effective functions of the community was in demonstrating to nonpsychotics that internal factors often were more responsible for their maladjustment than the external factors they frequently blamed. The psychotic patients who used paranoid thinking presented somewhat the same problem, and in many cases they responded to group processes in such a way that their paranoid systems were either modified or more narrowly delimited. The other patients soon recognized that such persons were very ill, and responded to the staff’s requests for assistance in defining reality to them.

Sharing of Feelings by Staff. One of the most difficult problems encountered and one which still remains is that of the staff’s reluctance to share their feelings with patients and with each other. It is difficult to know just how much personal information and feelings staff members should reveal in group discussions. In general it is believed that any feelings that, when unexpressed, interfere with any phase of community functioning or relationships should be openly discussed if the occasion arises. Initially, it seemed that the ward corpsmen were reluctant to follow this course, because they saw in it an obliteration of the distinctions between them and the patients. The natural extension of their thought was that they themselves might be considered to be mentally or emotionally ill.

It is not possible in the therapeutic community for the feelings and behavior of any member, including the staff, to be immune from scrutiny, because all are interrelated. This problem has been stated by Jones:

If the concept of free communication and analysis of current tensions is implicit in the treatment ideology of a therapeutic community, it is difficult to see how the staff can escape the need to face this challenge. A distinction is sometimes made between what is relevant to the treatment situation and what pertains to the individual’s private life.3

It is not believed that this aspect of this community’s functioning has yet been worked out satisfactorily. Recently a change was instituted to require all available staff members to attend all large group meetings and all staff conferences, and it is believed that this was a step in the right direction. Daily staff meetings following the large group meeting are still held, and in addition the closed ward staff meets early each morning. Also a weekly meeting has been established in which staff members are encouraged and in fact urged to express their feelings about each other freely, or about patients if the feelings constitute a hindrance in their dealings within the community. Progress has been slow insofar as staff members freely expressing feelings about each other is concerned; yet in general it is believed that such an approach is necessary.6 Recently, in a meeting, one of the enlisted staff corpsmen expressed his personal antipathy toward one of the staff officers present. This was considered to have been a real achievement in terms of the over-all process, because military protocol and training is such that this is not only discouraged but prohibited. The authors consider that the difficulties manifest in this staff’s communication are bound up in what might be called a group “transference neurosis" which has developed. It is believed that if this can be worked through, the everyday conflicts and difficulties which arise among the staff will be much less of a problem.

SUMMARY AND CONCLUSIONS

This article reports some of the problems that repeatedly arose in the daily group meetings of a therapeutic community and the methods developed to cope with them. The community is still in a transitional stage, but it is believed that other hospitals will experience similar transitions in adopting community methods of treatment.

Community methods of treatment focus on social tensions existing between patients, between staff members, and between staff and patients. The daily group meetings, seen as teaching and teaming situations for good social behavior, have been used to stimulate discussion of interpersonal tensions existing within the community. In the developmental stages of creating such an atmosphere, it was found necessary to deal directly with certain issues that arose frequently within the meetings. We found it necessary to require patients and staff to reveal the identity of persons involved in the discussions who had committed asocial or antisocial acts. Because of the shortness of the length of stay for most patients, the acculturation process and conscience development had to be hastened. In some instances this necessitated legal action toward an individual member for the welfare of the community, but for the most part, these matters were handled successfully within the group.

Passive, dependent attitudes of members toward their participation in the community came up frequently. These were treated as resistances to treatment and were verbalized in the meetings in such complaints as that the staff evaded answering their questions, that the group could not help individual members with their problems (that they required a doctor’s aid), and that they had no problems.

The participation of the staff in the community still remains unsettled. Some of the staff felt insecure in the relaxation of former controls, and were only slowly able to transform to new roles in which they could feel comfortable.

 

ACKNOWLEDGMENT: We are grateful to Captain Ira C. Nichols, MC, USN, for his advice; and to the nurses and hospital corpsmen who participated in this program, in particular to Commander Ellen Dolloff, NC, USN; Lieutenant Commander Mary Wolfgang, NC, USN; Lieutenant Marion Wardell, NC, USN; and Ben Geiger, Hospital Corpsman, second class, USN.

 

REFERENCES

1. Rundle, F. L., and Briggs, D. L.: Beginnings of therapeutic community. U. S. Armed Forces Medical Journal . 8: 811-819, June 1957.

2. Jones, M.: The Therapeutic Community— New Treatment Method in Psychiatry. Basic Books, Inc., New York, N. Y., 1953.

3. Wilmer, H. A.: Psychiatric service as therapeutic community. U. S. Armed Forces Medical Journal. 1. 7: 640-654, May 1956.

4. Wilmer, H. A.: Psychiatric service as therapeutic community; ten-month study in care of 939 patients. U. S. Armed Forces Medical Journal. 7: 1465- 1469, October. 1956.

5. Jones, M.: Personal communications.

6. Briggs, D. L.: Hospital corpsman as social therapist; an important role in psychiatric treatment. Medical  Technicians Bulletin (Supplement to the U.S.Armed Forces Medical Journal)  8: 169-176, July-August. 1957.

 



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